BERKELEY COLLEGE

Office of Disability Services

Application for Disability Services and Accommodations

The Americans with Disabilities Act (ADA) and other federal and state laws require colleges to provide reasonable accommodations of disabilities (modifications or adjustments designed to enable a qualified person with a disability to participate in a College program or activity). This process begins upon the students request. The types of accommodations available under Berkeley's Disability Policy are based upon the individual's documented disability and the College's ability to provide assistance without incurring undue burden or fundamentally altering its programs, facilities, policies or activities.

Students who should submit this form are:

Prospective students seeking accommodations during Admissions process (e.g. extended time on Admissions Exam) or for a campus visit

Admitted students who will be attending Berkeley College

Current students who have not applied for disability services and/or accommodations at Berkeley College

Students requesting housing accommodations and/or the use of a service animal in housing

Current students with a temporary disability

Students who should NOT submit this form are:

Students seeking support on the basis of a short/acute illness (e.g. seasonal flu). In such instances, students should contact their advisor for assistance.

Sections to be completed by the student: Sections to be completed by a

Health Care Provider:

I. Student InformationX. Health Care Provider Information

II. Academic Information

III. Referral Information

IV. Previous School Information

V. Disability Information and Documentation

VI. Student Narrative/ Statement on Impact

VII. Accommodations and Services

VIII. Confidentiality and Release of Information

IX. Student Information for Health Care Provider

Individual requests for accommodations may be referred to the specific campus ADA/Section 504 Coordinators: [NY students] Adam Rosen, Psy.D., 212-986-4343 ext. 4216 orAMR@BerkeleyCollege.edu; [NJ students] Sandra Coppola, Ph.D., 973-278-5400 ext. 1320 orSEC@BerkeleyCollege.edu; [Online students] Katherine Wu, Ed.M., LMHC, LPC, 973-405-2111 ext. 1394 orKNW@BerkeleyCollege.edu. In addition, each individual campus has a Disability Services representative via the Personal Counseling Office. These Personal Counselors work with the ADA/Section 504 Coordinators for the purpose of reasonably accommodating students with disabilities. A student seeking accommodations must schedule an appointment with either the above-stated ADA/504 Coordinators, or a campus Personal Counselor, in order to submit an Application for Disability Services and to confirm requested accommodations. Contact information for the College Personal Counselors can be found on the Berkeley College Health and Wellness website at: http://berkeleycollege.edu/10231.htm . Select Contact Information from the drop-down menu.

Berkeley College Office of Disability Services

Application for Disability Services and Accommodations Cover Page

Today's Date:_______________ Semester _________ Year ______

I. Student Information

Note: All email communication from Office for Disability Services will be sent to your Berkeley College

e-mail address once assigned by the college.

Student: ______________________________ DOB: ________________ Student ID#: ___________________

Address: ______________________________________________________________________________________________

Phone: _____________________________ Berkeley College E-mail: ___________________________________________

Campus Location:____________________________________________________________

Check one of the two options below:

I am new to disability services at Berkeley College. This is my first application for disability services and/or accommodations.

I am returning to the office of disability services.

ADA Coordinator: ______________________________________________________________________________

When did you first receive services? Indicate semester and year________________________________________

Name of Berkeley College Academic Advisor:________________________________________________________________

Telephone Number:_____________________________________________________________________________________

E-mail Address:_________________________________________________________________________________________

Are you currently receiving tutoring services from the Center for Academic Success? Yes No

Are you currently receiving services from the New York or New Jersey state Vocational Rehabilitation System (ACESS-VR) for a documented disability?

Are you currently receiving services for a documented disability from New York, New Jersey, or other sate Vocational Rehabilitation Services? Yes No

Office of Disability Services

Application for Disability Services and Accommodations- Student Information

New York

State Commission for the Blind and Visually Handicapped

Adult Career and Continuing Education Services Vocational Rehabilitation (ACCES-VR)

New Jersey

Commission for the Blind and the Visually Impaired

New Jersey Division of Vocational Rehabilitation Services

Other state __________________

If so, please indicate the following information regarding your state Vocational Rehabilitation counselor:

Name of Counselor: _______________________________________________________________________________________

Address: _______________________________________________________________________________________

Telephone Number:_____________________________ Fax Number: _____________________________

E-mail address: ________________________________________________________________________________________

Are you currently receiving services for a documented disability from a community based agency that provides services for people with disabilities? Yes No

Name of Agency _______________________________________________________________________________________

Address: _______________________________________________________________________________________

Telephone Number:_____________________________ Fax Number: _____________________________

E-mail address: ________________________________________________________________________________________

II. Academic Information

First semester (or anticipated) at Berkeley College_________________________________________

Anticipated graduation date(month/year)_________________________________________________

With which school/s are you affiliated: Larry L. Luing School of Business School of Graduate Studies School of Health Studies School of Liberal Arts School of Professional Studies

Degree or Certificate Program:___________________________________________________________

Semesters completed at Berkeley College to date: _______________________________________

Will you live on campus this semester? Yes No

Check all that apply:

I am an International student

I am an athlete (specify team affiliation)

I am a military veteran (specify VA affiliation if applicable):

III.Referral Information

Please indicate how you heard about Disability Services (check all that apply):

Berkeley College Website Berkeley College Student Family Member Professor

Academic Advisor/Dean Counseling Services ADA Coordinator Student Orientation

Admissions Associate Other:________________________________

IV.Previous Schools and Accommodations

Previous school/s attended

Dates attended (from-to)

List all approved disability accommodations and services from previous school/s

V.Disability Information & Documentation

Specify your disability type(s) - check all that are applicable:

Physical or Mobility PsychologicalChronic Medical Condition

Specify:___________________ Specify:__________________ Specify: __________________

Deaf or Hard-of Hearing Blind or Low Vision Attention Deficit/Hyperactivity Disorder

Traumatic Brain InjuryLearning DisabilityOther:______________________

Primary disability type for which you are requesting accommodations: ________________________________________________________________________________

Date of diagnosis/es:__________________________________________________________________

Please provide information about the disability documentation you will be submitting to our office.

Note: you are responsible for ensuring your documentation meets the Office of Disability Services

documentation guidelines.

Name of Provider on Documentation:__________________________________________________

Dates of Documentation (month/year): _________________________________________________

Type(s) of Documentation:

Learning Disability, AD/HD, Psycho-Educational, or Neuropsychological Evaluation

Disability Verification Form

Letter from Treatment Provider

Letter from previous school confirming approved disability accommodations

Other:______________________________________________________________________________

Only complete the section(s) below that apply to your documented disability(ies). After you have completed the appropriate section, move on to Section VI.

Part A: Deaf or hard-of-hearing Part B: Visual disability or blind Part C: Physical/mobility disability, or temporary injury

A. To be completed only by individuals with a hearing disability or who are Deaf:

Do you wear hearing aids or cochlear implants? yes no If yes, check all that apply:

Behind-the-ear hearing aids: Do they have Direct Audio Input (DAI)? yes no

In-the-ear hearing aids In-the-canal hearing Cochlear implant

Cochlear implant - body worn processor My device has telecoils

Have you used a neckloop with telecoils? yes no

My device has a M-T (microphone-telecoil) switch

Do you or have you used an FM system/assistive listening device in the past? yes no

If yes, please specify type (brand, model):

If yes, how does/did sound get to your ear?:

neckloop earphone (in the ear) cochlear implant headphone (over the ear)

Do you use captioned media? yes no

What means of expression and receptive communication do you use? Check all that apply:

Oral Communication Speech Reading American Sign Language Signing Exact English

Speech-to-text transcription (e.g. CART, C-Print) - Please specify your preferred type:

Other (specify):

B. To be completed only by individuals with a visual disability or who are blind:

Visual Acuity (if applicable):Right Eye:Left Eye:

Degree of Blindness: Total Light PerceptionForm Perception

Travel Aids: Cane Service Animal Other:

Do you use Assistive Technology? Specify type(s):

Do you use alternate format reading materials? yes no

If yes, indicate your preferred alternate format from the following:

Large Print Specify font size and type (e.g. 20 point bold, sans serif font):

If you use large print, specify whether it is used for visual subjects only (e.g. math, science, art) or for all subjects:

Electronic Format. Specify file type (e.g. Word, DAISY, audio file, accessible PDF):

Braille

Other (specify):

C. To be completed only by individuals with a physical or other mobility disability, or temporary injury:

Which, if any, of the following mobility aids do you use?

Prosthesis (specify): BracesCrutchesCane

Manual Wheelchair Motorized wheelchair/scooterOther (specify):

Do you have a state issued handicapped parking permit? yes no

Do you use stairs? (If so, specify general number tolerable): VI. Student Narrative/Statement on Impact

The purpose of this section is to serve as a supplement to the disability documentation you submit by way of self-report. In this section, you are prompted to describe the limitations you experience and how those limitations impact your academic performance/participation in Berkeley College's programs/campus and outside the classroom. This information helps us better understand your reason(s) for requesting accommodations at Berkeley College. Should you need more room to complete this section, please feel free to include an addendum.

a) List the specific cognitive/academic difficulties you experience related to your disability (e.g. reading, writing, concentration, memory, time management, note-taking, etc.) that may impact your ability to complete your coursework or other program requirements.

b) Please describe your academic performance at Berkeley College thus far or from your most recent school.

c) Provide any information about your program that you feel is important and relevant to your accommodation request.

d) How does your disability affect you in your everyday life, daily activities, getting around campus, social interactions, outside the classroom?

e) How have accommodations been helpful to you in the past? If you are requesting accommodations for the first time, please describe the reason(s) accommodations were not needed previously.

VII. Accommodations and Services

Please specify the accommodations you are requesting. Disability Services will consider your request in light of your disability as described in your supporting documentation, and other information provided to Disability Services, as well as the requirements of your specific academic program.

Campus Accommodations:

Elevator and lift access - specify location(s):

Locker on campus - specify location:

Orientation and Mobility Training

Accommodations for campus visit - date of visit:

Specify accommodations:

Classroom Accommodations:

Note-taking services

Permission to use laptop for note-taking in class

Permission to audio record lectures

Accessible classroom and furniture - specify your need:

Other classroom accommodations:

Exam Accommodations:

Extended time for in-class exams and quizzes Amount requested: minutes per hour

Distraction reduced environment for quizzes and exams

Scribe for exams (answer recorded/written for student)

Reader for exams

Use of computer for exams - specify:MAC PC No preference

"Stop the clock" rest breaks: Up to 15 minutes per hour of exam time

Accommodations for Admissions Exam or other placement/waiver exams (for any Berkeley College school). Specify Exam(s):

Specify Accommodations (if different from above):

Other exam accommodations:

Academic Accommodations:

Modifications to course requirements

Specify course/request:

Priority Registration

Training to use Assistive Technology Programs such as:

JAWS for Windows, Kurzweil 3000, ZoomText, and Dragon Naturally Speaking

Other academic accommodations:

Communication/Technology Accommodations:

Sign-language interpreters

Assistive listening devices (e.g. FM or Infrared systems)

Real time captioning (CART)

Captioned videos, podcasts, or other media

Assistive Technology

Specify type:

Textbooks in alternate format

Electronic text- Microsoft Word format Electronic text- structured PDF

Large print (specify font sizes and styles):

Audio format (specify):

Other:

Other Accommodations:

Other accommodations - specify:

Should you have questions about completing this form, about your disability documentation, or if you wish to learn more about the application process, you are welcome to email the Director of Disability Services at sharon-mclennon@berkeleycollege.edu

Berkeley College Office of Disability Services

Application for Disability Services and Accommodations- Student Information

VIII. Confidentiality & Release of Information

Confidentiality:

Berkeley College acknowledges that student disability records contain confidential information. A student's disability records are maintained in a confidential file with Disability Services (DS). Documentation concerning disabilities is separate from the student's general academic record. Eligibility and receipt of accommodations will not appear on a students academic transcript.

Disability-related information provided to DS is considered anEducation Record; therefore it falls under the protection of theFamily Educational Rights and Privacy Act(FERPA). FERPA permits DS to share information about the impact of a disability and accommodation eligibility with other Berkeley College school officials who have a legitimate educational interest. A school official includes, but is not limited to, ADA Coordinators, faculty and instructional staff, residence life staff, academic deans and advisors, career services, public safety and counseling. Legitimate educational interest means the school official needs to review an Education Record or information derived therefrom in order to fulfill his or her professional responsibilities. Generally speaking, faculty and college staff outside the Office of Disability Services do not have the right or need to view diagnostic information related to your disability; rather, they might need to know your accommodation eligibility and your accommodations. Sharing this need to know information with school officials does not require student consent under FERPA.

______Please initial here to evidence your understanding of FERPA in the disabilities context.

However, student disability related medical records may be protected by separate state and/or federal laws. To the extent that a state or federal law requires your consent before DS shares disability related information with school officials with a legitimate interest in the information, your signature below authorizes that sharing.

This authorization will be deemed effective for the entire period you are enrolled at Berkeley College. This authorization can be revoked if and when you submit a written request to do so directly to the Director of Disability Services. This authorization begins at the time this form is submitted and applies during times away from Berkeley College including, but not limited to, breaks between semesters, medical leave, studying abroad, etc.

Name of Student (Please print)_________________________________________________

Signature of Student__________________________________________________________

Student ID# ________________________ Date __________________________

Disclosures to Third Parties

Written consent IS required for the release of disability related records to non-school officials. Berkeley College staff will provide disability documentation to a specified individual or entity after a student has provided written authorization or consent. Students are responsible for specifying what information they wish to share and with whom via a FERPA Authorization to Release Student Records form found here: https://transforms.berkeleycollege.edu/iFiller/iFiller.jsp?fref=6ea5fc31-b08f-4290-b67b-a9cba033d8a6

For more information on the privacy and release of student Education Records, please refer to the College FERPA Policy found here: http://berkeleycollege.edu/files_bc/FERPA_Notice_Berkeley_1099.pdf

Berkeley College Office of Disability Services

Application for Disability Services and Accommodations- Confidentiality and Release of Information

IX. Student Information for Health Care Provider

Students: Review instructions and fill out information below before giving to your health care provider. (Please Print Legibly or Type)

Berkeley College Office of Disability Services Page 15 of 16

Application for Disability Services and Accommodations- Health Care Provider Information

Full name: ___________________________

Student ID#:__________________________

Home phone: (_______) - _______ - ______

Cell phone: (_______) - _______ - ______

Work phone: (_______) - _______ - ______

Best number to reach you:__________

Best days/times to reach you: _____________________________________

Instructions

The outline below has been developed to assist you in working with your treating or diagnosing healthcare professional (psychiatrist, psychologist, counselor, therapist, social worker, medical doctor, optometrists, speech-language pathologists etc.) to obtain specific information. This information will be used to evaluate eligibility for academic accommodations.

A. The healthcare professional(s) conducting the assessment and/or making the diagnosis must be qualified to do so. These persons are generally trained, certified, or licensed to diagnosis medical conditions.

B. All parts of the form must be typed and completed as thoroughly as possible. Inadequate information and incomplete answers will delay the eligibility review process by necessitating follow up contact for clarification.

C. The healthcare provider should attach any reports that provide additional related information (e.g. psycho-educational testing, neuropsychological test results, medical records, etc.). If a comprehensive diagnostic report is available that provides the requested information, copies of that report can be submitted for documentation in addition to this form.

D. The information provided by your healthcare provider will be kept in your file at the office of the ADA Coordinator and the Director of Disability Services, where it will be held confidential. This form may be released to you at your request. In addition to the requested information, your healthcare provider may attach any other information he/she thinks would be relevant to your academic adjustment/accommodation.

X. Healthcare Provider Information

Filled out by Healthcare Provider and returned to student

Please sign & date below and completely fill in all other fields

Provider Name (Print):__________________________________________________

Title:

______________________________________

License or Certification #: ___________________________________

Address:_____________________________________________________________________

______________________________________

Phone Number:_______________________________

Fax Number:___________________________

E-mail Address:______________________________

Provider Signature:_____________________________________ Date:____________________

DIAGNOSTIC INFORMATION (Please Print Legibly or Type)

1. Date of Diagnosis: ___________________________________________________________________

2. Primary Diagnosis: __________________________________________________________________

Secondary Diagnosis: ________________________________________________________________

3. What is the severity of the disorder? Mild Moderate Severe

4. Please state and describe the medication and/or treatment the student is currently prescribed:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

5. Major Life Activities Assessment: Please check which of the following major life activities listed below are affected because of the disability. Indicate severity of limitations.

Life Activity

Negligible

Moderate

Substantial

Dont Know

Concentration/ Attention

Memory

Eating

Social Interactions

Self-Care

Regular Class Attendance

Speaking

Learning

Reading

Thought Process

Communicating

Keeping appointments

Mood

Stress Management

Managing internal distractions

Managing external distractions

Sleeping

Organization

Hearing

Seeing

Mobility

Other: Please specify

6. What specific symptoms/functional limitations based on the diagnosis does the student have that might affect him/her in the academic setting?

7. Describe any situations or environmental conditions that might lead to an exacerbation of the condition.

8. State specific recommendations regarding academic accommodations for this student, and a rationale as to why these accommodations/services are warranted based upon the students functional limitations. Indicate why the accommodations are necessary (e.g. if a note taker is suggested, state the reasons for this request related to the students diagnosis).

Accommodations

Rationale

9. If current treatments (e.g. medications, counseling, etc.) are successful, state the reasons why the above academic adjustments/accommodations/services are necessary. Please be specific.